197610296-11-12-2024-31-AS-ASEA-DAXS7Z-20241112123823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610296
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:38:35 PM

Document Has Been Signed on 11/12/2024 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LINDLEY ASSISTED LIVING		FACILITY NUMBER:	197610296
ADMINISTRATOR/ DIRECTOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	18122 VINTAGE STREET		TELEPHONE:	(818) 983-2224
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 5	DATE:	11/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Larisa Bobakova		TIME VISIT/ INSPECTION COMPLETED:	12:37 PM

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On 11/12/24 at 09:50 AM, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPAs met with caregiver Larisa Bobakova and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 11:00 AM and observed the following:

The Kitchen area was toured, and LPAs observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your left-hand side. It is fully charged. The expiration date is 04/2025. There is a telephone line on the counter in the kitchen. There is extra, food in the kitchen pantries. The first aid kit is on the kitchen counter area on the left-side of the sink. The knives are at the top of the kitchen counter on your right-side in a locked black box and inaccessible to the residents.

The medications are locked and inaccessible to the residents in one of the top, black cabinets on your left-hand side at the entrance of the facility.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool/body of water.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINDLEY ASSISTED LIVING	FACILITY NUMBER: 197610296
	VISIT DATE: 11/12/2024

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Bedrooms: There are six (6) bedrooms and four (4) full bathrooms. There is two (2) half bathrooms. Two (2) of the resident’s rooms have private bathrooms. Only five (5) resident rooms are single and occupied. One (1) is vacant. There is no staff room. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 110–112.5-degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff. There Is another fire extinguisher on your right-hand side fully charged. There is no fireplace.

There is a pantry/room in the hallway that has extra linen and food storage. It is locked and inaccessible to the residents. The house temperature is at 71-degree Fahrenheit.

The smoke detector/carbon monoxide is in the hallway and is operable.

The washer/dryer along with the chemicals is in the hallway in a locked room, inaccessible to the residents. There are three pantry rooms with extra food, linen, incontinence, and chemicals that are also locked and inaccessible to the residents.

Administrative: There is no annual fee that is due right now. In the dining room/living room are on your right-hand side there is a billboard with House Rules, Disaster Plan, Resident Rights, Theft and Loss Policy, Rights of Resident Council, Licensee Expiration dated 01/2025, Infection Control and the surety bond with an expiration date of 01/2025. There was a fire drill that was conducted and up to date..

An exit interview was conducted, no citations were issued, and a copy of this report was issued to the caregiver.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC809 (FAS) - (06/04)

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